Preventing falls in older adults is a high-priority public health issue. A large proportion of the population is at risk; approximately 30% of those over age 65 fall every year. The Centers for Disease Control and Prevention (CDC) reports that there were 35.6 million falls by older adults in 2007, 1.8 million of which resulted in injury. Of these fallers, 32% needed help with daily activities, almost 200,000 needed help for more than six months, and 15,800 died as a result of their fall. Even a minor injury puts the faller at significantly increased risk for another fall, based on data collected by the Centers for Medicare and Medicaid Services (CMS). Falls frequently result in short- and long-term health consequences and increased health care utilization.
Although major fall prevention research programs have been underway since the 1990's, there has been little change in the incidence of falls among older adults. Only a few fall prevention approaches have had some success, primarily those involving clinical assessments of fall risk and/or exercise interventions (see Hendrich, U.S. Pat. No. 7,282,031; Lach et al, Falls in the elderly: Reliability of a classification system, J Amer Ger Soc, 1991, 39(2), 197-202; Tinetti et al, Fall risk index for elderly patients based on number of chronic disabilities, 1986, Am J Med, 80(3), 429-434; Tinetti et al, A multi-factorial intervention to reduce the risk of falling among elderly people living in the community, N Engl J Med, 1994, 331(13), 821-827). However, there are considerable problems associated with these methods. For example, clinical intervention is resource-intensive and many physiological problems of older adults cannot be corrected. Also, individuals have varied response to exercise prescriptions and many participants do not follow the recommended program. Although a variety of technological methods to help reduce falls have been developed (e.g., assessing a person's fall-risk, detecting whether a fall has occurred, protecting against fall-related injury), these approaches have also had limited success. Examples of such technological methods known in the field are described by Panzer et al (Biomechanical aspects of quiet standing and changes associated with aging, Arch Phys Med Rehabil, 1995, 76(2), 151-157) and by Azzarro et al (U.S. Pat. No. 7,612,681). Because the primary cause of a fall is usually context-specific and since fallers tend to be poor historians, it is difficult for practitioners using these approaches to identify specific functions, actions, or environmental characteristics that may lead to a fall.
In addition, numerous studies have shown that behavioral change is not easy to accomplish. Studies have found that programs that simply provide fall prevention advice are often seen as useful in principle but not personally relevant because their recommendations are regarded as ‘common sense’. Such advice may also be seen as a threat to one's identity and personal autonomy. Research has shown that behavioral change programs are most successful when individuals are motivated to change and feel they retain control.
A key barrier to successful fall prevention is the resistance of older adults to change their habits or modify familiar settings. Simply stated, seniors are reluctant to make changes. A Canadian study found that 20% of the seniors in the study refused to modify their home environment as recommended, even when there were no costs involved. Of those who agreed to modify their environment, a followup visit found that only 50% of these modifications were still in place 12 months later. These findings underscore that people resent being told what to do and prefer to come to the need for change on their own. Changing one's behavior or home environment is seen differently if it stems from one's own ideas and they feel they have control of the situation.
Of the many studies on behavior change, Gibson's pioneering work in the field of Ecological Psychology is especially relevant to the prevention of falls (see Gibson, The theory of affordances, in R E Shaw & J Bransford (Eds.), 1977, Perceiving, acting and knowing: Toward an ecological psychology. Hillsdale N.J., Erlbaum). Gibson focused on training individuals to recognize opportunities for action in their environment and to use their abilities to take advantage of such opportunities. For example, recognizing that a doormat could cause a fall provides a person an opportunity in the future to prevent a fall by noticing a doormat, holding onto something, lifting one's feet, or simply avoiding the doormat altogether. Linking perception to action in this way can directly affect behavior by encouraging individuals to recognize ‘Fall Threats’ (situations that are more personally relevant to them than the more commonly known ‘Fall Risks’) and take appropriate action. Successful interventions train individuals to quickly identify Fall Threats in various real-world situations and devise their own unique fall prevention solutions on the fly.
Because falls are caused by a variety of underlying issues, what is needed is a multifactorial approach that focuses on a host of behavioral, psychological, physiological, and environmental factors for the purpose of increasing an individual's awareness of Fall Threats and changing certain behaviors to reduce their risk of falling. The present Multimedia Fall Prevention (MFP) method and system uses such an approach, incorporating 21st century advances in digital and multimedia technologies to create a personalized fall prevention program for each participant which addresses their unique lifestyle and the characteristics of their environment.
The three major components of the present invention incorporate these principles. First, the MFP interviews that a trainer (user) conducts with his/her clients focus on issues that are very relevant to each client, translating an individual's fall history, physical, social and environmental characteristics into Fall Threats that are personally meaningful and help the client establish his/her own goals. Next, the interactive MFP training sessions allow the user to focus the client's attention on Fall Threats that take into account their particular lifestyle and any physical limitations they may have. Finally, the MFP evaluation sessions determine which Fall Threats a client is able to detect before, during, and after MFP training, thereby measuring the extent to which the individual's awareness of Fall Threats has changed. The evaluation findings also create an opportunity for the user to recommend enhanced clinical treatments and/or fine-tune cognitive or behavioral interventions to help the client in other ways.
A unique advantage of multimedia technology is that it presents multiple representations of a concept to address individual styles of learning. Visually experiencing what was once abstract leads to a positive sense of mastery. Multimedia technology takes advantage of the fact that our visual systems process 40% of sensory input, with our auditory channels also playing a major role. Because clients use many of their sensori-motor skills, they are much more likely to be actively involved during the training and learn from the experience. Multimedia technology also enables the user to assess a client's ability to process sensory information, which may lead to improved treatment and/or changes in the individual's environment.
Furthermore, multimedia technology helps fallers recognize Fall Threats in realistic and familiar situations that exist in their daily life. Individuals learn how to make their own decisions about appropriate fall prevention behaviors, which promotes a sense of optimism and self-mastery. Using real-life multimedia scenes for evaluation allows the user to identify Fall Threats that the client does not recognize and provides treatment outcome measures when used as a pre/post-test. Enabling patients to recognize real-life challenges can help them reduce their fear of falling and promote self-mastery.
Awareness of personal safety is a hallmark of successful fall prevention, however, many people who have lost some functional mobility do not see how it could affect their personal safety. Recent studies of 195 subacute rehabilitation inpatients demonstrated that a majority of them were overconfident with respect to performing certain everyday functions. The evaluation component of the MFP system permits examining whether there is a mismatch between perceived and actual abilities, which is helpful in determining a patient's readiness for discharge from a rehabilitation setting.
To test whether the present invention (MFP training using interactive multimedia vignettes) is more effective than traditional training (without vignettes), a randomized double-blind trial with 292 participants was conducted by the inventor. The subjects were randomly assigned to one of two fall prevention trainings (with or without the vignettes) and the participants in each group were tested after the training to assess their recognition of Fall Threats in 10 novel scenes. A univariate, sequential analysis of variance was performed on the number of Fall Threats recognized as a function of gender, age, treatment (with or without multimedia vignettes), and practice time (whether they attended one or two training sessions). The study found that the participants who received MFP training with multimedia vignettes recognized significantly more Fall Threats one month later than those in the non-vignette training (p=0.001). Customizing the vignettes to include five features that were personally relevant to each participant resulted in an even greater awareness of potential Fall Threats (p<0.001), as did the addition of a practice session (p=0.026). Interestingly, the participants' gender and age were not found to have independent effects on outcome.
In a longitudinal followup study, 212 of these participants ranging in age from 60-96 years old kept daily logs and were telephoned weekly by independent research associates blinded as to study group. Measures were taken of the amount of time that had elapsed until a subject recorded new fall prevention measures and the time until his/her second fall. The subjects were followed for up to 56 weeks and the standard Medicare criterion was used to determine if the subject had a second fall during this period. Cox survival models were used to evaluate the main effect and interactive effect on outcome of the subjects' gender, age, and extent of impairment. The study found that women reported new fall prevention measures sooner than men, especially those whose training had included multimedia vignettes. Among those who participated at least 12 weeks (n=171), both men and women who had received multimedia training (n=111) were significantly less likely to experience two falls during the followup period than those who had not (p=0.016). The addition of multimedia resulted in significantly fewer falls in as little as 12 weeks, and this outcome was observed in both sexes.
To understand whether the cognitive and behavioral changes that result from viewing the MFP vignettes actually influence the likelihood of a fall, the inventor used structural equation modeling to evaluate the deterministic relationships between the subject variables (gender, age, and extent of impairment) and progressively more distal outcome measures (number of fall threats recognized, number of new prevention behaviors recorded, time to second fall, and average number of falls per week). The study found that awareness of one's unique Fall Threats and the execution of new fall prevention behaviors were both significant factors in preventing falls. When Fall Threat recognition (cognitive) and personal action (behavioral) components were removed, the power of the intervention was significantly diluted and the remaining fall prevention effects were attributed primarily to the extent of the subject's physical impairment.
The research findings summarized above show that the present invention, when used with older adults, is effective in increasing an individual's awareness of Fall Threats and changing key behaviors to reduce their risk of falling. The relatively low cost of MFP components permit this new fall prevention program to be delivered in practically any setting, including community senior centers and other non-medical settings. The MFP method and system has the potential to significantly reduce the number of falls experienced by millions of older adults each year, thereby increasing their life expectancy and quality of life.